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MONITORING WELL INSTALLATION REPORT <br /> Date: CONSTRUCTION <br /> Premise Address: Total Depth <br /> Screen Length (from)' (to) <br /> Well No.: Filter Pack (from) (to) <br /> Bentonite' (from) (to) <br /> Inspector: Grout (from) (to) <br /> Drilling rig type <br /> Permit No. Auger O.D. I.D. <br /> Drilling Company: Completion- Stove pipe/christie box (circle one) <br /> Driller: casing <br /> height <br /> Consultant <br /> Geologist —QV <br /> ABOVE-GfiOUND <br /> CON.?L mON CHRM'TY-BOX <br /> SPECIAL PERMIT INFO. Grour)d gu{2ce COMPLETION <br /> Distance to sewer line Qrout <br /> Domestic well on site - (y/n) 1 ft <br /> If yes, location and distance - <br /> ft. _ <br /> A _ <br /> SAMPLING — <br /> slotted `' = c <br /> wc5on � _ <br /> Holding Temperature y . _ VIVE4 Pack <br /> Method —_ <br /> Screening Method _ <br /> Tracking Sheet - (y/n) _ <br /> SPOILS <br /> 4 <br /> Storage Method MATERIALS/DEVELOPMENT <br /> Contamination Noted - (y/n) <br /> Storage Location Casing type <br /> Blank ft. Screen ft. <br /> Slot size <br /> GROUTING Bags cement <br /> Buckets bentonite <br /> Depth to water Bagssand/ <br /> Mix Ratios Filter Pack type/size <br /> Installation Method (_y_/na_ —_— <br /> Quantity Installed Discussed with geologist: - (y/n) <br /> Type of method <br /> EH 29 29 <br /> 0 <br />